Page 20 - Tree Line - North Carolina Forestry Association - First Quarter 2023

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PLEASE FILL OUT AND RETURN WITH PAYMENT
NOTE: This form is for NEW hunt clubs. Existing clubs and landowners need to contact the NCFA office at (919) 834-3943.
order to obtain a hunting lease or timberland insurance, all parties have to be a member of the NCFA.
NCFA’s Hunting Lease Liability Insurance Application
NAME OF HUNT CLUB:____________________________________________________________________________________
Contact:________________________________________________________________NCFAMember#: _________________
Address: __________________________________________________________________________________________________
City: ____________________________________________ State: ______________ ZIP Code: _________________
Phone: _______________________________________________________________________________________
E-mail: ________________________________________________________________________________________
The club must have a written lease with all landowners for coverage to apply.
NAME OF LANDOWNER: _________________________________________________ NCFA Member #:______________ (person, partnership or corporation)
Landowner Representative (If different from above):___________________________________________________
Address: _________________________________________________________________________________________________
City: ____________________________________________ State: ______________ ZIP Code: _________________
Phone: ________________________________________________________________________________________
E-mail: ________________________________________________________________________________________
Total Number of Acres: ____________________ County: ______________________________________________
Leasing from more than one landowner? Please attach a separate sheet with the above information for each landowner.
PREMIUM CALCULATION: COMPLETE OPTION 1 OR 2 (please check one)
OPTION 1: $1 Million General Liability Limit OPTION 2: $2 Million General Liability Limit
ACREAGE RANGE
✔
OPTION 1
$1 MILLION PLAN
✔
OPTION 2
$2 MILLION PLAN
ACREAGE RANGE
✔
OPTION 1
$1 MILLION PLAN
✔
OPTION 2
$2 MILLION PLAN
Less than 500 $200.00 $370.00 1001-1500 $280.00 $520.00 2001-2500 $440.00 $815.00
3001-3500 $575.00 $1,065.00 4001-4500 $740.00 $1,370.00 More than 5000 $0.15 / Acre $0.28 / Acre
501-1000
$235.00
$435.00
3501-4000
$650.00
$1,205.00
1501-2000
$360.00
$670.00
4501-5000
$775.00
$1,435.00
2501-3000
$495.00
$915.00
Signature of Landowner: _____________________________________________________ Date:______________
Please make check for insurance payable to AssuredPartners or visit www.apoutdoorinsurance.com to apply & pay online. Mail form and payments to: Assured Partners, P.O. Box 21627, Columbia, SC 29221
Coverage is subject to approval by AssuredPartners. Master Policy effective date is August 1 to August 1. Applications received after August 1 of a given year will be effective upon approval and will expire on the following August 1.
18 ncforestry.org / FIRST QUARTER 2023